Binge Eating to be Added to List of Mental Health Diagnoses

Imagine not being hungry and eating anyway … eating so much that your stomach aches … eating so much that you’re nauseated … eating until your jaws are sore from chewing. And then eating some more.

It’s called binge eating disorder, and it’s expected to be included as a formal psychiatric diagnosis in the next American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. DSM-IV, currently in effect, lists three diagnoses of adult eating disorders: anorexia nervosa, bulimia nervosa and “eating disorder not otherwise specified.” Binge eating is lumped into that third category, which refers to several kinds of abnormal eating patterns that don’t have consistent symptoms. DSM-V, expected to be published in May 2013, will therefore have four distinct eating-disorder diagnoses.

Elisa Gitan, a licensed clinical social worker and therapist at Centerstone in Nashville, described an episode of binge eating as “like a wild animal that hasn’t eaten in months, frenzied and out of control.” Yet binge eaters don’t follow the episode with a compensatory behavior, such as self-induced vomiting. Because they don’t purge, she explained, weight gain and even serious obesity may result.

Criteria for diagnosing binge eating disorder have been tested in field trials by the APA throughout the summer and are continuing. The panel of psychiatrists that recommended binge eating as a diagnosis defined it as patients who eat amounts of food at one sitting that are “definitely larger than most people would eat in a similar period of time under similar circumstances.” The patient must also perceive a lack of control. Binges must occur at least once a week for three months, and patients must express “marked distress” over them.

Additionally, patients must have at least three of the following behaviors or symptoms:

eating much more rapidly than normal,

eating until feeling uncomfortably full,

eating large amounts of food when not feeling physically hungry,

eating alone because they’re embarrassed by how much they’re eating, and

feeling disgusted with themselves, depressed or very guilty after overeating.

Panel members have stated that there’s ample evidence in the literature that binge eating is distinct from bulimia and is clearly not just an extreme of normal behavior.

What makes matters worse is society’s scorn of the obese. “Our society is really geared toward blaming the individual for being overweight, yet someone being super-thin is promoted by media. Obesity brings with it a certain judgment,” Gitan said. The result is binge eaters who hide their disorder and fail to seek treatment.

“There’s a huge secrecy issue for all of these disorders whether it’s anorexia, bulimia or compulsive overeating, which you could categorize as a food addiction. It’s basically an obsessive-compulsive relationship with food,” Gitan said. She noted that eating disorders could go hand-in-hand with other mental health diagnoses, such as depression, anxiety, addiction or even post-traumatic stress disorder. In such cases, the eating disorder manifests itself as a symptom of a larger mental health challenge. “So it’s all about treating the core issues,” she said.

Whether there’s a genetic component to eating disorders is the subject of much research, and two chromosomes in particular (1 and 10) have been linked to both anorexia and bulimia. Once a definitive link is made, health insurers might be more willing to lift caps on the amount of treatment allowed for eating disorders, Gitan noted.

“Genetics loads the gun, and environment pulls the trigger,” said Reba Sloan, a licensed registered dietician in private practice in Nashville. Sloan specializes in eating disorders, weight management and wellness nutrition. She said genetics, and perhaps brain chemistry, predispose certain people to disordered eating, yet she doesn’t believe eating disorders are addictions.

Sloan said America’s addiction to dieting is the root of the problem. “Most people who develop an eating disorder aren’t overweight prior to the eating disorder, but our society makes every woman feel compelled to lose weight,” Sloan said, adding that she’s seeing an increase in the number of her clients who are male. “I believe that for every person we can stop from going on that first diet, we could be potentially preventing an eating disorder.” She also eschews the body mass index, calling it “absolutely ridiculous. Most professional athletes would be categorized as obese according to BMIs.”

Sloan’s assertions come from a personal perspective: She suffered anorexia, starting at age 13, for about a decade. When her parents took her to the Mayo Clinic for help, she recalled, “A psychiatrist sat across from me and said, ‘Oh, I know your problem. When you get mad at your parents, you pull your hair out.’” Actually, Sloan was losing her hair because of near starvation.

“When you haven’t been through it, it’s certainly a hard thing to understand, the cognitive dissonance that goes on in the mind,” she said.

Thankfully, medicine today has a more enlightened view of eating disorders, yet Sloan is concerned that some early attempts at prevention – such as discussions about the disorders in middle school health classes – “could maybe actually put the idea in their brains.”

One of the most telling pieces of research when it comes to dieting’s link to disorders is the Minnesota Semi-Starvation Experiment, conducted at the University of Minnesota in 1944-45. “It shows how closely dietary restriction is aligned with the development of eating disorders,” Sloan said. Participants were severely rationed food, yet the physiological effects weren’t as stunning to researchers as the psychological. Participants exhibited depression, hysteria, social withdrawal and even self-mutilation. Participants hoarded food and binged.

“I believe everybody in the medical field, all teachers and anybody who works with children needs to be involved in preventing dieting. We need to be exposing the fallacies of the diet industry, the artificial norms we are told we need to achieve,” Sloan said.

Sloan and Gitan agree that eating-disorder treatment should be a multipronged approach. “There really needs to be an integrated type of treatment plan where people are not only seeing a therapist, but the therapist is working with a medical doctor who’s monitoring the physical issues that derive from these disorders,” Gitan said. She may refer her behavioral therapy patients to psychiatrists, nutritionists and even alternative practitioners such as acupuncturists or yoga specialists.

On the other hand, Sloan, the dietician and nutritionist, won’t accept clients with a severe eating disorder unless they are also working with a therapist, even though her master’s is in behavioral counseling. “An eating disorder never, ever develops just about food, eating and weight,” she said.